POLICY/PROCEDURE TITLE:
Human Milk Preparation Room
Procedures
WOMEN & INFANTS SERVICES
RELATED TO:
ADMINISTRATIVE
CLINICAL
PAGE 1 OF _
Medical Center Policy (MCP)
Nursing Practice Stds.
Effective date: 10/3/2011 Revision date:
JCAHO
Patient Care Stds.
Unit/Department of Origin: NICU/Nutrition
QA
Other
Other Approval: Infection Control, Environmental Services,
Nutrition Department
Title 22
POLICY STATEMENT:
To provide guidelines for the storage and handling of mother’s milk to optimize nutritional
and immunological protection as well as growth and development. Maximize patient safety
through the use of the Mothers’ Own Milk System (MOMS) bar-coded tracking system.
Assuring aseptic technique is used in preparation.
RESPONSIBLE PARTY:
Providers’ Responsibilitiy: Daily review of feeding tolerance and growth. Modification of
orders and update to maximize growth.
Nurses’ Responsibility: Management of mothers’ milk and patient safety through MOMS,
support human milk production through education and monitoring of milk volume daily, and
aseptic technique in handling milk. Communicates daily feeding plan of care to the Milk Tech by
completing the daily fortification of breast milk request form for the Milk Tech placing it in the
collection box by 0900 daily. Receive breast milk into the MOMS system for processing by the
Milk Tech.
NICU Hospital Unit Service Coordinators (HUSCs), Respiratory Therapists, and
Volunteers Responsibilities: Following training on the MOMS system, NICU HUSCs, selected
therapists and volunteers will receive mothers’ milk and donor milk into the MOMS system
placing in the freezer or refrigerator as designated by the bedside RN, print out milk bottle labels
for the mothers, distribute sterile containers and labels for milk collection and storage, and
transfer milk using the MOMS system from the nurseries to and from the Milk Tech prep area.
HUSCs only will monitor all breast milk refrigerators for temperature compliance logging any
required documentation.
Nutrition (Milk) Tech Responsibility: Preparation, labeling, and storage of mothers’ milk
using the MOMS bar-coded patient safety system. Aseptic technique used in all preparation.
Equipment maintenance and ordering of supplies.
Environmental Services (EVS) Responsibilities: Daily cleaning of milk prep room in the
morning before preparation starts at 0900. Daily removal of trash on the evening shift after
1600.
Infection Control: Monthly audit of compliance to policy and report out to NICU Manager,
Nutrition Supervisor, and EVS Supervisor.
Nutrition Department: Supervisor partners in supervision of Milk Tech with NICU Manager for
compliance to policy and annual policy review. Teaches aseptic procedure. Monitors supply
inventory ordering additional supplies as needed to maintain par levels.
DEFINITIONS:
Fresh Milk: Milk at room temperature at approximately 20 degrees Centigrade (68F) or
refrigerated at 4 degrees Centigrade.
Frozen Milk: Milk held at approximately -20 degrees Centigrade (14F) or -70 degrees
Centigrade (-36 F).
Thawed Milk: Milk that has been previously frozen.
Mothers’ Own Milk System (MOMS): Bar-coded human milk tracking system capable of
tracking individual specimens, labeling once fortified, and monitoring expiration. Provides a safe
patient environment through positive identification of milk samples with the correct patient and
assuring milk discharged with the patient. Creates reports for available bottles for feeding and
feeding history.
EQUIPMENT:
Mothers’ Own Milk System program on laptop or handheld PDA with barcode scanner
Zebra printer for printing MOMS labels and rolls of labels (storehouse)
Refrigerator set to 2-4 degrees Centigrade with Awarepoint temperature monitoring system
Measuring scale to assure correct grams of fortification additives
Disposable packaging and labeling for preparation of prepackaged fortification additives to be
used in the NICU by Nursing.
Containers for breast milk distribution (120 ml specimen containers, 250 ml, 500 ml, and 1 liter
containers, and a variety of syringes—10 ml, 20 ml, 30 ml, and 60 ml)
Red caps for syringes
Glass beakers for mixing
Disposable tubs for transfer and thawing of individual patient milk orders
Sterile tongue blades for stirring
Medicine cups
Sterile water for mixing dry formulas
Powdered formulas (Neosure, and as ordered
Fortifiers (Neosure powder, Beneprotein, Simply Thick, Human Milk Fortifier, and as ordered)
Hair nets
Non-sterile gloves
Masks
Ink Pen
Antiseptic hand gel
Paper towels
Antiseptic spray for surface cleaning
Non-sterile towels for prep area
Recipe book for infant formulas and fortifications
Step stool
Carts for transport of milk
Calculator
Scrubs for milk techs available in the NICU
PROCEDURE:
Milk Tech preparation of human milk and prepared formulas and additives will be
completed in the 7th Floor Diet Kitchen, 7-250. Pager for the Milk Tech is (619) 290-0711.
1.
Pick up Diet Kitchen keys in the Diet Office on the First Floor and any equipment from
the dishwasher for use in preparation. Back up keys in the NICU Manager office on the
bulletin board.
2. Collect the previous day’s census as a reference for workload.
3. Retrieve HUSC Census Report form from the NICU front desk in the NICU, 2-701. This
report will contain a list of babies in nurseries A, C, D and 4ISC.
4. Collect the milk order cards from the bin in Nursery A and in the 4ISC. If cards are
missing, ask the nurse. Highlight names on the census for orders that need to be filled.
5. Calculate the total volume of milk that is needed by multiplying the number of feedings
by the per feeding volume.
6. Check refrigerators for prepared milk and fresh milk quantities. Record the number of
prepared syringes on the census sheet. Collect the fresh milk that is not older than 24
hours and place in the individual patient bin using MOMS to transfer the milk to the 7th
floor refrigerator bin created specifically for that one patient with a bin label.
7. Place surplus fresh milk not yet expired and older than 24 hours in the mother’s freezer
bin for future use if the infant is on fortified feedings to avoid the expiration period that is
implemented by the system often disallowing some of the prepared feedings to be used
when scanned by the RN at feeding time.
8. Discard in the MOMS system any already expired milk. Discarded milk can be run down
the drain and plastic containers placed unwashed in the recycle bin as long as the labels
are removed.
9. Preference should be given to using the oldest milk in the freezer first when selecting
frozen milk for use.
10. Use the handheld bar-code scanner to change the status from fresh to frozen as it is
moved to the freezer. Frozen milk may be stored up to 12 months in the hospital -20
Centigrade degree freezers.
11. If there is not enough fresh milk to fill an order, acquire more from the freezer where the
mother’s bin is kept. There are 2 freezers in the 2nd floor NICU arranged alphabetically
and include the donor breast milk inventory. The 4th floor breast milk freezer is located in
the Diet Kitchen, 4-250 (door code 1-5), and contains the 4ISC mothers’ bins and any
surplus donor milk inventory.
12. Check Donor supply. Page NICU Manager to reorder if there is less than a 1 week
supply.
13. Retrieve a slightly higher milk volume for each order than calculated for use.
14. Prioritize the milk fortification by the urgency (i.e. Baby A has 1 syringe left prepared for
feeding and Baby B has 2 syringes left, prepare Baby A’s order first). Plan to have the
feeding orders transferred to the nursery refrigerators by at least 15 minutes prior to the
scheduled feeding where it is required.
15. With the handheld bar-code scanner, move milk from the patient unit refrigerator bin to
the tech bin assigned to the 7th floor Diet Kitchen refrigerator in the MOMS system.
16. Defrost frozen milk in plastic bin assigned to patient and labeled using warm water, not
hot to touch.
17. Use the Nutrition Department Recipe Guide for preparation of the milk ordered on the
daily order card from the nurse. If the milk card order is unclear, discuss with the nurse
for clarification and consult the Registered Dietitian if additional consult is required to
clarify the order. She may be paged 24/7 for recipe clarification.
18. Aseptic technique will be used in preparing the recipe with appropriate personal
protective equipment (hats, mask, gloves) and scrub clothes will be worn under the hood
in the milk prep room.
19. Milk techs will clean off all work surfaces using the antiseptic spray provided following
noted directions for contact time prior to preparation of milk and between orders on
surfaces that come into direct contact with milk.
20. Milk Techs will follow proper hand hygiene by washing hands prior to cleaning surfaces
and again between cleaning surfaces and preparing milk. Hand washing between
orders is expected and after removing gloves. Antiseptic hand gels may be used and
are mounted in the Milk prep area. The sink in the milk prep room may not be used by
other non-milk tech personnel during the milk preparation procedure.
21. Milk Techs will wear a hair net, mask, and non-sterile gloves for milk preparation at the
hood. Open milk containers should be covered with a 4 x 4 cloth to prevent ambient air
particulate matter from dropping into the feeding during preparation. The hood should
be turned on during feeding preparation to assure best air flow to support this process.
22. The sterilized graduated cylinders will be used to prepare the fortification order.
23. Once the milk is mixed and stored in syringes with red caps, use the handheld bar-code
scanner to update status.
a.
b.
c.
d.
Prepare—combine all bottles into one.
Prepare—fortify, using the supplements included in the order.
Prepare—print labels for all syringes.
If only a partial bottle is required, use the “Split” function to use part of the bottle now
and save the rest for future use. Unused fresh milk can be frozen for future use and
should be moved to the mothers’ freezer bin in MOMS as well as placing it in her
freezer bin.
24. Label each container with the preprinted labels from the MOMS system.
25. Deliver the orders to the appropriate bins in the nurseries refrigerators using the MOMS
system to move them back from the Tech bin assigned to the 7th floor refrigerator. Put
the oldest formulas on top with a black “X” on the container to assist the RN in locating
which containers need to be used first.
26. Return the milk card to the nurse. If the nurse is unavailable, put the milk card on the
patient’s file (clipboard). Inform the RN if there is less than a 2 day supply of milk left. It
will be the RN’s responsibility to notify the mother to bring in more milk.
27. Once all the milk orders are filled, finish all the end of day tasks.
a.
b.
c.
d.
e.
Use antiseptic spray on all surfaces assuring contact time while wet meets package
instructions. Store separately from milk prep equipment.
Run all used beakers through the dishwasher in the Nutrition Department.
Lock up all carts, Computer on Wheels, step stool, refrigerators, and cabinets.
Return the key for this area back to the Diet Office on the First floor and log/clock out
for the day.
Extra set of keys is kept by the NICU Nurse Manager. Cable locks have word
codes(Tell and Shall) that are given to the staff oriented to this procedure at
orientation.
Environmental Services (EVS) Daily Procedures for 7-250:
1. EVS supervisor will assure compliance with daily assigned tasks as defined by the
approved Infection Control audit tool posted in this room. The EVS worker assigned to
the Milk Prep Room will sign off on the EVS items daily.
2. Daily between 0700 and 0800, EVS will clean the 7th floor diet kitchen ensuring the high
dusting and work surfaces including the ones inside the hood with removable work
surface, sinks, and floors are cleaned.
3. Daily removal of all trash and recyclables. PM shift removal after day of prep is
recommended time for removal with double check at 0700-0800 cleaning. Trash
receptacles are to remain covered.
REFERENCES:
“Infant Feedings: Guidelines for Preparation of Formula and Breast Milk in Health Care
Facilities,” Pediatric Nutrition Practice Group of the American Diatetic Association, 2003.
Human Milk Banking Association of North America (HMBANA) 2011, Best Practices for
Expressing, Storing, and Handling of Human Milk in Hospitals, Homes and Childcare Settings.
Raleigh, NC, HMBANA
“Breast Milk/Mothers’ Milk: Collection, Storage, and Preparation” Policy, Women and Infants
Division, last update 10/2010.